Provider Demographics
NPI:1083085898
Name:GRAVES, HOLLY DAWN (APRN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:DAWN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:DAWN
Other - Last Name:WILT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1101 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3705
Mailing Address - Country:US
Mailing Address - Phone:316-788-6963
Mailing Address - Fax:316-788-5373
Practice Address - Street 1:1101 N ROCK RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3705
Practice Address - Country:US
Practice Address - Phone:316-788-6963
Practice Address - Fax:316-788-5373
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76970-122364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health